Denials

Published 02/23/2023

October – December 2022, Outpatient Services Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 13X bill type in South Carolina, North Carolina, Virginia and West Virginia.

Rank

Denial Code

Denial Description

# Claims

1

55504/55503

No Medical Necessity

4157

2

53NCD/54NCD

No Diagnosis/Documentation to Support Medical Necessity (Bene Liable/ Provider Liable)

4135

3

52NCD

NCD Denial — HCPCS/Diagnosis Matched National Coverage Determination (NCD) Table List ICD9-CM Deny Codes

228

4

5D164/5H164

Documentation Submitted Does Not Support Medical Necessity

224

5

56900

Auto Denial — Requested Records Not Submitted

209

6

5OP70

Service Is Subject to Prior Authorization and No UTN Is Present on the Claim

169

7

5D165/5H165

No Certification

60

8

5OP62

Item of Service Is Subject to Prior Authorization and No Prior Authorization Was Requested for the Item of Service

53

October – December 2022, Inpatient Hospital and Psych Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 11X bill type in South Carolina, North Carolina, Virginia and West Virginia.

Rank

Denial Code

Denial Description

# Claims

1

56900

Auto Denial — Requested Records not Submitted

34

2

55503

LCD Denial — No Medical Necessity

10

3

5D164

Documentation Submitted Does Not Support Medical Necessity

1

4

5D650

No Valid Certification, Recertification Present

1

5

5D800

Documentation Submitted Does Not Support Medical Necessity for Inpatient Psychiatric Services

1

October – December 2022, Skilled Nursing Facility Medical Review Top Denial Reason Codes
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing the 21X bill type in South Carolina, North Carolina, Virginia and West Virginia.

Rank

Denial Code

Denial Description

# Claims

1

5D002/5X002

Agree with Provider (Beneficiary Liable)

21

2

5D505

Certification Not Valid

5

3

5DOWN

Medical Review Downcode

5

4

5D504/5H504

Not Medically and Reasonable Necessary

3

5

56900

Auto Denial — Requested Records Not Submitted

2

6

5D510

Skilled Nursing Facility Benefits Are Only Available After an Eligible Covered Hospital Stay of at Least 3 Days

2

7

5D011/5X011

Agree With Provider (Provider Liable)

2

8

55503

LCD Denial — No Medical Necessity

1

9

5D508/5H508

Benefits Are Exhausted on a SNF Claim for Services Subject to Benefit Period Determinations

1

5D505 — Certification Not Valid

Reason for Denial
The certification or recertification is not submitted, not signed, not dated, or does not cover the dates of service in question.

To Prevent This Denial

  • A certification or recertification statement must be signed by an attending physician or a physician on the staff of the SNF who has knowledge of the case or a nurse practitioner who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician, or a clinical nurse specialist who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician. Initial certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable
  • The routine physician’s admission order is not a certification of the necessity for post-hospital extended care services for purposes of the Medicare program
  • When responding to a request for copies of medical records, submit the initial certification and/or subsequent recertifications related to the look back periods and the dates of service under review

More Information


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